James M. Paci

Knee Medial Compartment Contact Pressure Increases With Release of the Type I Anterior Intermeniscal Ligament

Background The anterior intermeniscal ligament of the knee is at risk during knee arthroscopy, anterior cruciate ligament reconstruction, and tibial nail insertion. Hypothesis Release of the anterior intermeniscal ligament, in knees with type I ligaments, will result in altered contact pressures in the medial compartment. Study Design Controlled laboratory study. Methods Five fresh-frozen human cadaveric knees with intact type I anterior intermeniscal ligaments were chosen for testing in a modified MTS machine from 0° to 60° of flexion under 2 conditions: (1) intact and (2) after sharp sectioning of the anterior intermeniscal ligament. Measurements were made using inframeniscal contact pressure sensors covering the medial compartment. Poststudy analysis was done in 10° increments between 0° and 60° of flexion, looking at peak contact pressure and the amount of contact area seeing pressure. Results Sectioning of the anterior intermeniscal ligament caused a statistically significant increase in the peak pressure at 20°, 30°, 40°, and 50° of knee flexion. The largest change occurred at 40° of knee flexion, when the peak pressure increased by 27.5% (3.68 MPa to 4.69 MPa). Contact area decreased, although this difference was not statistically significant. Conclusion Release of the anterior intermeniscal ligament results in increased peak contact pressures in the medial compartment of the knee. Clinical Relevance Care should be taken to avoid sacrifice of this ligament during surgery.

Cannulated Screw Fixation of Refractory Olecranon Stress Fractures With and Without Associated Injuries Allows a Return to Baseball

Background: An olecranon stress fracture is a rare injury associated with valgus extension overload in baseball players. No long-term outcomes studies have been published documenting the results of surgical fixation of olecranon stress fractures with or without concomitant injuries in baseball players. Hypothesis: Open reduction and internal fixation (ORIF) of an olecranon stress fracture will reliably produce bony union and allow a successful return to the previous level of activity in competitive baseball players. Study Design: Case series; Level of evidence, 4. Methods: Twenty-five patients treated with ORIF for an olecranon stress fracture at least 2 years earlier (range, 2-10.14 years) were retrospectively contacted to complete a telephone survey; 18 of 25 (72%) patients responded. Data were collected to determine the return to play rate, level of arm pain, and overall arm function. Results: All 18 stress fractures went on to successful union; 17 of 18 (94%) athletes returned to baseball at or above their previous level. Average return to play time was 29 weeks. The numeric analog pain score was 0.2 at rest and 0.3 when throwing at the time of follow-up, at an average 6.2 years (range, 2.0-10.14 years) after surgery. The average score at follow-up on the Disabilities of the Arm, Shoulder and Hand Outcome Measure–shortened version (QuickDASH) was 4.1 (range, 0-27.3). Ten (56%) patients required 13 additional future surgeries on their throwing arm; 7 surgeries in 6 (33%) patients were not related to the index surgery. Six of 18 (33%) patients underwent hardware removal, with 2 (11%) for infection. Conclusion: Open reduction and internal fixation of olecranon stress fractures in competitive baseball players has a high rate of success in returning players to or above their former level of play and allows for good elbow function at an average of 6.2 years postoperatively. However, these patients are at high risk for additional future surgeries on their throwing arm.

Distal Triceps Knotless Anatomic Footprint Repair: A New Technique

Distal triceps rupture is a rare injury causing significant disability. Several techniques for treating distal triceps ruptures have been described using bone tunnels or suture anchors. More recent techniques have focused on re-creating the anatomic footprint of the distal triceps tendon. However, the increasing numbers of anchors used increase the risk to the articular surface, and all earlier techniques require knot tying and bulky knots beneath the thin posterior elbow soft-tissue envelope. We describe a technique combining the use of bone tunnels and a single suture anchor to create a knotless anatomic footprint repair of the distal triceps. By using this technique, we are able to create a tension-band construct that self-reinforces the anatomic repair and is very low profile while significantly decreasing risk to the articular surface.

Results of Laboratory Evaluation of Acute Knee Effusion After Anterior Cruciate Ligament Reconstruction What Is Found in Patients With a Noninfected, Painful Postoperative Knee?

Background Infection after anterior cruciate ligament reconstruction is a rare and potentially devastating complication. No normative data have been reported for knee aspiration after anterior cruciate ligament reconstruction in the early postoperative period. Hypothesis Determining normative laboratory data from a retrospective review of noninfected early postoperative anterior cruciate ligament reconstruction knee effusions will allow for the calculation of an aspirate white blood cell (WBC) threshold value indicative of infection. Study Design Case series (diagnosis); Level of evidence, 4. Methods A 2-year retrospective chart review of 151 anterior cruciate ligament reconstruction patients was performed. Thirty-one noninfected patients meeting the inclusion and exclusion criteria and 1 infected patient had laboratory data collected, including peripheral blood and knee effusion aspirate analyses. Laboratory data from pertinent published studies of infected knees after anterior cruciate ligament reconstruction were combined with the data of our 1 infected patient, establishing a historical control group. Data were analyzed and results were then compared. Infected aspirate WBC threshold value statistics were then calculated. Results Analysis of noninfected knee effusion aspirates revealed a mean WBC count of 9600/uL (standard deviation [SD], 15 200), and a mean of 66% polymorphonuclear (PMN) cells (SD, 34). Aspirate WBC 98% confidence interval (CI) was 2800/uL to 16 200/uL, and the 98% CI for PMN cells was 58% to 84%. Aspirate WBC count >16 200/uL is 86% sensitive, 92% specific, and has a positive likelihood ratio of 10.4 as an indicator of infection. Conclusion Benign effusion after anterior cruciate ligament reconstruction is common and is associated with elevated inflammatory markers. When concerned, knee aspiration after anterior cruciate ligament surgery gives the highest yield to differentiate between a painful effusion and a septic knee in the early postoperative period while awaiting definitive culture results. The authors report confidence intervals defining the range of cell count variables for noninfected patients requiring aspiration, specifically WBC and PMN, and suggest a WBC threshold value of >16 200/uL be used as an indicator of infection. On the basis of comparison with historical control data, the authors believe these data are significant and will be reliable for clinical use.

Diffusion tensor imaging of human Achilles tendon by stimulated echo readout-segmented EPI (ste-RS-EPI)

Healing, regeneration, and remodeling of the injured Achilles tendon are associated with notable changes in tendon architecture. However, assessing Achilles microstructural properties with conventional diffusion tension imaging (DTI) remains a challenge because of very short T2/ T2* values of the tendon. Hence, the objective of this study was to develop a novel Achilles tendon DTI protocol for a non‐invasive investigation of the changes of microstructural integrity in tendinopathy.

Patellar Tendon Repair Augmentation With a Knotless Suture Anchor Internal Brace: A Biomechanical Cadaveric Study:

Background: Patellar tendon repair with braided polyethylene suture alone is subject to knot slippage and failure. Several techniques to augment the primary repair have been described. Purpose/Hypothesis: The purpose was to evaluate a novel patellar tendon repair technique augmented with a knotless suture anchor internal brace with suture tape (SAIB). The hypothesis was that this technique would be biomechanically superior to a nonaugmented repair and equivalent to a standard augmentation with an 18-gauge steel wire. Study Design: Controlled laboratory study. Methods: Midsubstance patellar tendon tears were created in 32 human cadaveric knees. Two comparison groups were created. Group 1 compared #2 supersuture repair without augmentation to #2 supersuture repair with SAIB augmentation. Group 2 compared #2 supersuture repair with an 18-gauge stainless steel cerclage wire augmentation to #2 supersuture repair with SAIB augmentation. The specimens were potted and biomechanically loaded on a materials testing machine. Yield load, maximum load, mode of failure, plastic displacement, elastic displacement, and total displacement were calculated for each sample. Standard statistical analysis was performed. Results: There was a statistically significant increase in the mean ± SD yield load and maximum load in the SAIB augmentation group compared with supersuture alone (mean yield load: 646 ± 202 N vs 229 ± 60 N; mean maximum load: 868 ± 162 N vs 365 ± 54 N; P < .001). Group 2 showed no statistically significant differences between the augmented repairs (mean yield load: 495 ± 213 N vs 566 ± 172 N; P = .476; mean maximum load: 737 ± 210 N vs 697 ± 130 N; P = .721). Conclusion: Patellar tendon repair augmented with SAIB is biomechanically superior to repair without augmentation and is equivalent to repair with augmentation with an 18-gauge stainless steel cerclage wire. Clinical Relevance: This novel patellar tendon repair augmentation is equivalent to standard 18-gauge wire augmentation at time zero. It does not require a second surgery for removal, and it is biomechanically superior to primary repair alone.

Knotless Tape Suture Fixation of Quadriceps Tendon Rupture: A Novel Technique

Quadriceps tendon ruptures disrupt the extensor mechanism of the knee and require urgent surgical management. Traditional repair techniques have had mixed biomechanical and clinical results risking weakness and extensor lag. We describe a novel technique using tape suture and knotless anchors, which has performed superiorly during biomechanical testing and yielded terrific early clinical results.

Clinical Evaluation of an Arthroscopic Knotless Suprapectoral Biceps Tenodesis Technique: Loop ’n’ Tack Tenodesis

Background: Pathology of the long head of the biceps tendon is a well-known cause of shoulder pain that is commonly managed with arthroscopic suprapectoral biceps tenodesis when conservative treatment fails. Purpose: To present an arthroscopic knotless suprapectoral biceps tenodesis technique known as “Loop ’n’ Tack” tenodesis and to report the clinical outcomes of patients with a minimum 2 years of follow-up. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review of all patients who had undergone Loop ’n’ Tack tenodesis between January 2009 and May 2014 was completed. Charts were reviewed, and patients were contacted for demographic data, time from surgery, concomitant procedures, and workers’ compensation status, as well as visual analog scale for pain, American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and University of California, Los Angeles (UCLA) scores. Results: Complete follow-up evaluations were performed for 59 of 68 patients (87%). Mean follow-up was 43 months. A majority (88%) of patients had at least 1 additional procedure performed at the time of biceps tenodesis. The mean ASES shoulder score improved from 42.6 preoperatively to 91.0 postoperatively (P < .001), and 54 of 59 patients (91.5%) had a good/excellent outcome, with a UCLA shoulder score >27 and ASES shoulder score >70. Three patients (5%) reported biceps cramping pain with overuse, and 2 (3.3%) reported intermittent anterior shoulder pain. No patients had developed a “Popeye” deformity at final clinical examination, and 97% reported that they were overall satisfied with the procedure. Conclusion: The Loop ’n’ Tack tenodesis technique results in a high rate of patient satisfaction, significant improvement in shoulder outcome scores, and a low incidence of postoperative pain, with no reoperations for biceps-related pathology.

Type 4 SLAP Tear in 21-Year-Old Minor League Centerfielder

Superior labrum anterior to posterior tears (SLAP) are a common injury in the overhead athlete. While most of these injuries involve type I or type II tears in this population, infrequently type IV tears will be encountered. These are difficult injuries to treat because the pathology involves both the labrum and the biceps tendon and may be associated with chronic throwing-related changes to the glenohumeral joint. Labral, biceps, and other associated pathology may need to be addressed nonsurgically and/or surgically for a successful outcome and return to play. The following case highlights the diagnosis, nonoperative and operative treatment options, and the postoperative rehabilitation for treatment of a type IV SLAP lesion in an overhead athlete.

Predictive Value Of Preseason Screening In Collegiate Baseball Pitchers

Objectives: High level baseball pitchers are prone to shoulder and elbow injuries, resulting in significant morbidity and missed time from sport. This is the first study to use both subjective and objective preseason evaluations of baseball pitchers to predict injuries that occur in-season. We hypothesize that athletes reporting unfavorable scores on subjective questionnaires, and athletes falling outside the established pre-season normative values for objective data are more likely to develop injuries in season. Methods: Over three collegiate baseball seasons from 2011 through 2013, a cohort of collegiate Division I baseball pitchers underwent both objective and subjective evaluation prior to the start of the fall collegiate season. Preseason analysis included range of motion (ROM) in 5 planes, upper extremity manual muscle testing (MMT), Functional Movement Screen (FMS) assessment, a Kerlan-Jobe Orthopaedic Clinic (KJOC) Overhead Athlete Shoulder and Elbow score, an Upper Extremity Patient History (UEPH) questionnaire, and a Modified American Shoulder Elbow Score (MASES) questionnaire. This cohort was monitored over the course of the subsequent season for the development of injury and missed game time. A descriptive analysis for each questionnaire and all objective variables was performed. Univariate and multivariate regression models were used to explore potential risk factors for upper extremity (UE) injuries. Scatter plots, Spearmans correlation coefficients, and corresponding p-values were used to examine the relationship between subjective responses, objective physical parameters, and injury days missed. Results: Forty-two athletes participated in the study over three consecutive collegiate baseball seasons. Our preseason normative values for ROM, MMT, and the KJOC questionnaire are shown in Tables 1, 2, and 3. The mean KJOC score for our cohort was 86.93/100 (SD 12.49), and the mean MASES score was 88.4/100 (SD 21.7). The mean FMS score in our cohort was 15/21 (SD 3). Injury data for our cohort are shown in Table 4. After three full seasons, a lower KJOC score significantly correlated with injury days missed (Spearmans rho = 0.63, P-value 0.0122). Through the first two seasons, pitchers with a 1% higher UE rating on the UEPH questionnaire had 9.5% lower odds of developing injury during the season (OR 0.9149, 95% CI 0.8525-0.9819, P Value 0.014). Pitchers reporting every 1 unit higher of subjective instability had 61.27% higher odds of developing an UE injury (OR 0.6127, 95% CI 1.1044-2.3549, P value 0.013). However, by the end of the third season, and after adjusting for the use of pain medication, these variables failed to reach significance in our multiple regression analysis. Dominant shoulder TAM, rotator cuff strength, and glenohumeral internal rotation deficit (GIRD) were not predictive of injury in our cohort; although having over 5 degrees of difference in TAM vs the non-dominant shoulder approached significance (P-value 0.0598). Conclusion: This is the first study to demonstrate predictive value of subjective questionnaires. The KJOC Overhead Athlete Shoulder and Elbow Score can be used as part of the standardized preseason athlete evaluation to target pitchers at risk for developing injuries in-season. Objective parameters - notably TAM, GIRD, and rotator cuff strength - were not predictive of injuries in our cohort, which contradicts prior reports. To our knowledge, normative FMS data has not yet been established in baseball pitchers.